July/August 2017 Annals of Family Medicine

In recent years, US medical expenditures have outpaced inflation and are notably higher than those of other developed countries. A new study examines whether increases in expenditures on medical care are related to an increase in the overall number of services used, changes in the types of services provided, and/or the cost or intensity of services delivered. The study finds that, between 1996-1997 and 2011-2012, the number of Americans using medical services was unchanged in many categories of service, while expenditures for medical services increased in every category except primary care physicians and home health. Using nationally representative data, the study compared medical ecology (number of individuals using a service), utilization (number of services), and expenditures (dollars spent) in different categories of medical services. It finds that total expenditures increased by 47 percent, from $246 per individual per month in 1996-1997 to $362 per individual per month in 2011-2012, with large increases in dollars spent in every category except primary care physician and home health. The largest absolute increases were in prescribed medications, specialty physicians, emergency department visits, and likely inpatient hospitalizations. A large percentage of the increase (42 percent) related to increases in prescription drug use. In comparison, in 1996-1997, prescribed medications accounted for 12 percent of total expenditures. The number of individuals using medical services was unchanged in many categories of service (total, outpatient, outpatient physician, users of prescribed medications, primary care and specialty physicians, inpatient hospitalization, and emergency department), increased in other categories (optometry/podiatry, therapy, and alternative/complementary medicine) and decreased in dental and home health. The number of services used largely mirrored the findings for individual use, except for an increase in the number of prescribed medications and a decrease in primary care physician visits. Substantially curbing the trend toward higher medical expenditures, the author suggests, will require a greater commitment to working "upstream," at the sources of the challenges facing the US health care system.

http://www.annfammed.org/content/15/4/313

In an accompanying editorial, former Acting Assistant Secretary for Health Karen DeSalvo and Andrea Harris contend that, although payers and health systems are assuming greater financial risk for health outcomes, they are unable to adequately constrain costs and improve health outcomes because of patients' social needs. Like Johansen, DeSalvo and Harris call for health care leaders to take an upstream, public health approach, addressing such health-related issues as environment, housing, transportation, and access to healthy food and safe spaces. Such an approach will require structural changes to funding and accountability for individual and community health, they propose, with an ultimate goal of building healthier communities that support affordable, equitable health for all.

http://www.annfammed.org/content/15/4/304

Michael E. Johansen, MD, MS
Grant Family Medicine, Ohio Health, Columbus, Ohio

Karen DeSalvo, MD, MPH, MSc, New Orleans, Louisiana
Andrea R. Harris, MSc, Washington, D.C.

Although misuse of opioids and other pain relievers has reached epidemic proportions, afflicting approximately 2 million people in 2015, only 20 percent of patients who need treatment for opioid use disorder are receiving it. In this issue, the Annals of Family Medicine presents original research and commentary on medication assisted treatment for opioid use disorder and the role of primary care clinicians in treating the burgeoning epidemic.

More than half of rural counties in the United States lack a physician trained and waivered by the Drug Enforcement Agency to treat opioid use disorder using Buprenorphine Maintenance Treatment. Furthermore, many physicians with a waiver are not using it fully or at all. Rural waivered physicians participating in a national survey (n=1124) reported a range of concerns about prescribing buprenorphine including medication misuse, time constraints, and lack of available mental health or psychosocial support services. Waivered physicians who don't currently prescribe buprenorphine or have never done so (n = 321) were more likely than current prescribers to report the following barriers: time constraints, lack of patient need, resistance from practice partners, lack of specialty backup for complex problems, lack of confidence in their ability to manage opioid use disorder, concerns about Drug Enforcement Agency intrusions on their practice, and attraction of drug users to their practice. Physicians reporting other barriers (n=205) described administrative or infrastructure issues (told they cannot do it, don't have the space or staff) (18 percent), regulatory hurdles (including prior authorization and paperwork) (17 percent), difficult patients (12 percent), and stigma (9 percent). The study authors call for tailored strategies to address barriers to providing Buprenorphine Maintenance Treatment and to support physicians in adding or maintaining this service.

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C. Holly A. Andrilla, MS, et al, University of Washington

Buprenorphine reduces mortality for those with opioid use disorder, but periods off treatment are associated with much higher mortality rates. A study of 713 new outpatient users of buprenorphine was conducted in France, where patients with opioid use disorder are usually treated by general practitioners in private practice with periods in and out of treatment. The mortality rate for study subjects was 0.63/100 person-year [95 percent CI 0.40- 0.85], compared to 0.24/100 person-year [0.24-0.25] for other individuals of the same age range during the same time period. The authors encourage physicians to avoid interruption of treatment and encourage patients to remain in treatment for a sufficient amount of time.

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Julie Dupouy, MD, PhD, et al, Université de Toulouse, Toulouse, France

When a family physician moved to a new rural community, she was unprepared for the constant flow of patients seeking prescriptions for opioids. In this essay, she recounts her patients' denial and anger and her own feelings of frustration and burnout as she tried to balance good medical care with the wants of her patients. A turning point came when she received training in medication-assisted treatment for opioid addiction. Her role transformed from a "villain" trying to prescribe non-opioid therapies, to a coach. The decision to provide her patients and community with medication-assisted treatment, the author states, led to her professional healing. She calls on health care professionals to challenge their prescribing habits, recognize opioid addiction, and support one another in providing treatment.

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Nicole Gastala, MD, Marshalltown, Iowa

In a Point/Counterpoint, two doctors debate whether or not family physicians should provide medication-assisted treatment to their patients with opioid use disorder. Family physician David Loxterkamp states that family medicine, with its focus on relationships, communities, and team-based care, must be at the forefront of treating patients touched by this epidemic. Because family physicians know how to listen, care, and be present for their patients, Loxterkamp contends, they are well-qualified to treat addiction. In contrast, psychiatrist Richard Hill states that patients requiring medication assisted treatment need care from highly trained specialists in addiction medicine or addiction psychiatry who can treat both substance use disorder and co-morbid psychiatric disorders. Adding treatment for substance use disorder to the responsibilities of an already-overextended primary care workforce, Hill states, is an undue clinical burden.

Editorialists Richard Saitz and Timothy Daaleman contend that substance use disorder can only be treated successfully if primary care is a strong point of entry to care. Primary care physicians must be responsible for the initial and longitudinal care of patients with substance use disorders, and specialized services must be widely available and accessible. "Our nation will not be able to adequately respond to the current epidemic without addressing it in primary care and there is no question that the time to do it is now," they write.

David Loxterkamp, MD, Belfast, Maine
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Richard R. Hill, MD, PhD, Case Western Reserve University School of Medicine
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Richard Saitz, MD, MPH, FACP, DFASAM, Boston University School of Public Health Timothy P. Daaleman, DO, MPH, University of North Carolina at Chapel Hill
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A 2012 cervical cancer screening guideline change is associated with reduced testing for cervical cancer and chlamydia and reduced identification of chlamydia cases in young women. Screening for chlamydia, the most commonly-diagnosed bacterial sexually transmitted infection worldwide, is often conducted with cervical cancer screening. Using population-based physician billing claims data and public health surveillance data, researchers in Ontario, Canada assessed the population-level impacts of new cervical cancer screening guidelines recommending less frequent screening and older age of screening initiation. They found that Pap testing declined in all age groups following the guideline release, with the greatest relative reductions observed for females aged 15 to 19 years. The guideline change was also followed by a decrease in chlamydia testing in females aged 15 to 29 years. The largest reduction was observed in the 15 to 19-year age group (relative reduction of 26 percent), in whom cervical cancer screening is no longer recommended, suggesting that reduced chlamydia testing may have been an unintended consequence of the guideline change. Reduced chlamydia testing coincided with a reduction in reported chlamydia incidence in females aged 15 to 19 years and 20 to 24 years (relative reductions of 17 percent and 14 percent, respectively). In contrast, there were small increases in chlamydia testing in males aged 20 to 24 years and 25 to 29 years two years after the guideline change. Incidence rates were unchanged for males. The authors call for separating screening recommendations for sexually transmitted infections from recommendations for cervical cancer and highlight the need to promote chlamydia screening strategies for females that can be adopted into routine clinical care.

http://www.annfammed.org/content/15/4/329

Michelle S. Naimer, MD, MHSc, Mount Sinai Academic Family Health Team
Jeffry C. Kwong MD, MSc, Institute for Clinical Evaluative Sciences and Public Health Ontario, et al

Although deprescribing (tapering and withdrawing medicines when risks outweigh potential benefits) is essential to best prescribing practices, it runs counter to patient expectations, medical culture, and organizational factors. In a qualitative study of 24 primary care physicians in Auckland, New Zealand, participants recognized the importance of deprescribing for older patients, while identifying many barriers and few incentives to the practice. Less experienced physicians and those in short-term low-trust therapeutic relationships reported finding deprescribing challenging. The authors state that interventions to support safer prescribing should consider sociocultural influences, the importance to physicians of maintaining relationships, the sense of vulnerability many physicians feel in practice, and the organizational constraints they face.

Katharine A. Wallis, MBChB, PhD, MBHL, FRNZCGP, et al, University of Auckland, Auckland, New Zealand
http://www.annfammed.org/content/15/4/341

A health plan's ability to offer access to clinicians in primary and specialty care is crucial to ensuring access to care. New research finds that access to outpatient behavioral health care varies widely; depending on insurance company and level of training, 10-59 percent of clinicians can offer a new patient appointment, with psychiatry appointments particularly difficult to schedule. Using a secret shopper method, three researchers made 1,932 calls to behavioral health clinicians affiliated with three major insurance companies. Extrapolating from these findings, the authors estimate that a patient would need to call seven to 10 psychiatrists in order to find an available appointment. They point out that, given the stigma and fatigue associated with mental illness, difficulty in obtaining an appointment for behavioral health care is of particular concern.

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MariaElena O. Williams, MD, et al, University of Colorado

Between 2000 and 2014, the mobility rate of younger primary care physicians was approximately double that of older physicians. According to a study of rural primary care physicians' geographic mobility patterns, biennial turnover of younger physicians was around 17 percent, compared to 9 percent for older physicians, with little difference between rural and metropolitan physicians. Non-retention of physicians was significantly worse in rural counties without a hospital (6 percent), counties with a smaller population, and those with decreased physician supply (7 percent, per provider-to-population ratio/1000 step). The study, based on AMA Masterfile data, found no association with county-level economic or demographic measures. Female physicians of urban origin were more likely to leave rural practice. The study authors call on rural health workforce planners and policymakers to be cognizant of these key factors in guiding retention policies and support for vulnerable rural communities.

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Matthew R. McGrail, PhD, et al, Monash University, School of Rural Health, Churchill, VIC Australia

In primary care settings, training and support of clinicians has a lasting effect on the proportion of adult patients given an alcohol intervention at nine months. A cluster randomized factorial trial spanning four countries (England, the Netherlands, Poland, and Sweden) and the Catalonia region compares three strategies to increase delivery of screening and advice to heavy drinkers: clinician training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice. Researchers find that training and support have a longer-term effect on primary care clinicians' delivery of screening and advice to heavy drinkers as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool. Specifically, the ratio of the logged proportion given an intervention during the 12-week implementation period was 1.61 (95 percent CI, 1.24 to 2.10) in primary health care units that received training and support versus units that did not receive it. For financial reimbursement, the ratio was 2.00 (95 percent CI, 1.49 to 2.47); and, for training and support plus financial reimbursement the ratio was 2.44 (95 percent CI, 1.85 to 3.22). The study demonstrates a lasting effect of training and support at 9-month follow-up; the ratio of the logged proportion given an intervention at follow-up was 1.39 (95 percent CI, 1.03 to 1.88) in units that received training and support versus units that did not receive it. There was no lasting impact of financial reimbursement. The authors recommend training and support of primary care clinicians in delivering screening and brief advice, repeated over time, in order to increase the volume of brief interventions delivered to heavy drinking patients.

http://www.annfammed.org/content/15/4/335

Peter Anderson, MD, PhD, et al, Newcastle University, Newcastle, England

A new series of clinical decision rules integrating signs, symptoms, and C-reactive protein diagnose acute rhinosinusitis and acute bacterial rhinosinusitis with good accuracy. Researchers developed a point score and algorithm for each of 3 reference standards: abnormal CT scan, abnormal antral puncture, or positive bacterial culture. They conclude that the most appropriate reference standard is positive bacterial culture of antral puncture fluid. The point score using this reference standard successfully identified groups with a low (16 percent), moderate (49 percent) and high (73 percent) likelihood of acute bacterial rhinosinusitis. By identifying patients at low risk for a bacterial infection, this clinical decision rule can lead to more conservative use of antibiotics and help reduce inappropriate antibiotic prescribing. According to the authors, prospective validation of the findings and an assessment of their effect on clinical and process outcomes are important next steps.

http://www.annfammed.org/content/15/4/347

Mark H. Ebell, MD, MS, University of Georgia
Jens Georg Hansen, MD, DMSc, Aarhus University Hospital, Denmark

When patients are admitted to the hospital, their connection to their primary care physician is often disrupted, leading to difficult transitions of care, readmissions, higher costs, and worse health outcomes. Two family physicians propose a solution: the creation of the hospital chief primary care medical officer. The chief primary care medical officer, a primary care physician, would lead hospital efforts to create systems that ensure the primary care continuum is complete, even for complex patients. The position could be funded by savings that arise from improved value, the authors suggest, particularly as healthcare systems shift away from a focus on volume towards a focus on value. The authors call for a healthcare system that supports a trusting primary care relationship at critical junctures in individuals' lives.

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Noemi Doohan, MD, PhD, University of California Davis
Jennifer DeVoe, MD, DPhil, Oregon Health & Science University

Physicians regularly encounter losses: not only the death of patients but also more ambiguous losses, including changes in professional roles, duties, and identity. A family physician proposes that these ambiguous losses can cause stress and grief. If not acknowledged and addressed, physicians' grief can both contribute to burnout and be exacerbated by it. The solution, she suggests, is not resilience training for physicians but rather acknowledging their losses and supporting them in addressing their grief.

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Deborah Lathrop, MD, MAT, Madison, Wisconsin

In a medical culture that values technical prowess and the ability to make complex clinical decisions, personal reflection can help physicians cultivate their inner lives, emotions, and spirituality. Residents in a family medicine residency training program were given a protected 15-minute slot in their schedules to write reflections about their experiences with patients. They were not given specific writing prompts and did not submit their reflections for grading or response. Their writings described their struggles and joys in treating patients, goals for the future, and the search for meaning in their experiences. A focus on developing inner lives, the authors suggest, allows for the integration of the physician as both a professional and a person.

http://www.annfammed.org/content/15/4/379

Andrea Vicini, SJ, MD, PhD, et al, Boston College

Annals of Family Medicine continues its new feature, Innovations in Primary Care – brief one-page articles that describe novel innovations from health care's front lines. This issue's innovations include:

• Expanding Primary Care Access: A Telehealth Success Story – A widespread telehealth project in Brazil has reduced the wait for specialty consultations and appointments.
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• Using Patient-Entered Data to Supercharge Self-Management – Solo practices use a low-burden method to measure and improve the health confidence of their patient populations.
  http://www.annfammed.org/content/15/4/382

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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